As the coronavirus disease 2019 (COVID-19) pandemic continues, its impact on newborns remains uncertain. Early reports from China suggested that although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection could be associated with adverse pregnancy outcomes, newborns did not appear to show clinical signs of infection and had negative viral testing results.1,2 More recent reports suggest that, although low, risk of neonatal infection does exist. A recent (as we write this commentary) review identified 27 publications describing 217 newborns born to mothers with COVID-19, of which 21 publications describing 187 newborns were from China.3 Of the 217 newborns, 7 (3%) had evidence of SARS-CoV-2 infection: 3 had positive serum levels of immunoglobulin G and immunoglobulin M antibodies with negative polymerase chain reaction (PCR) test results, and 4 had positive PCR test results. Beyond the immediate postnatal period, in several case studies, authors report positive SARS-CoV-2 test results in symptomatic newborns in the first month of life, and new reports are published frequently.3–7 The mechanism of neonatal infection is unclear. Vertical transmission during pregnancy is not thought to be likely; SARS-CoV-2 test results on placenta, umbilical cord, amniotic fluid, vaginal secretions, and breast milk samples have uniformly been negative.8 More likely is postnatal infection through horizontal transmission.
This uncertainty around neonatal infection risk has led to notable variations in care practices for newborns born to mothers with COVID-19. Hospitals, professional organizations, and public health agencies have interpreted the limited available data in the context of their local environments to develop practice recommendations that then are applied to a wide range of clinical and social conditions. Although there is some agreement on certain aspects of newborn care, such as the use of precautions for delivery room resuscitation or isolation of exposed infants requiring intensive care, approaches to other aspects of care differ widely, including the location of care and breastfeeding for term infants that are well and born to mothers without severe symptoms. Recommendations on these areas from several national-level organizations as well as the World Health Organization (WHO) are summarized in Table 1. In China, consensus guidelines for mothers who are COVID-19–positive suggest immediate cord clamping and no mother-infant contact in the delivery room, isolation of the infant for 14 days after birth, and avoidance of breast milk use until mother has recovered from the infection.9,10 WHO supports skin-to-skin care, rooming-in, and breastfeeding for infants born to mothers with COVID-19.11 The Italian Society of Neonatology, the Royal College of Paediatrics and Child Health, and the Canadian Paediatric Society support rooming-in and breastfeeding with appropriate infection prevention measures for these infants, unless mothers are too ill.12–14 The American Academy of Pediatrics (AAP) suggests the separation of the mother who is COVID-19–positive and her infant when possible and use of expressed breast milk rather than breastfeeding.15 The Centers for Disease Control and Prevention (CDC) suggest shared decision-making between the family and clinical team with regard to the location of care as well as breastfeeding.16
Guidance on Location of Newborn Care and Breastfeeding for Mothers With COVID-19 From Selected Organizations
| . | Location of Newborn Care . | Breastfeeding . |
|---|---|---|
| China9,10 | Separation | No breast milk |
| WHO11 | Rooming-in encouraged | Breastfeeding encouraged |
| Italy12 | Rooming-in encouraged | Breastfeeding encouraged |
| Great Britain13 | Rooming-in encouraged | Breastfeeding encouraged |
| Canada14 | Rooming-in supported | Breastfeeding supported |
| AAP15 | Separation preferred | Pumping preferred |
| CDC16 | Shared decision-making | Shared decision-making |
| . | Location of Newborn Care . | Breastfeeding . |
|---|---|---|
| China9,10 | Separation | No breast milk |
| WHO11 | Rooming-in encouraged | Breastfeeding encouraged |
| Italy12 | Rooming-in encouraged | Breastfeeding encouraged |
| Great Britain13 | Rooming-in encouraged | Breastfeeding encouraged |
| Canada14 | Rooming-in supported | Breastfeeding supported |
| AAP15 | Separation preferred | Pumping preferred |
| CDC16 | Shared decision-making | Shared decision-making |
How can these disparate practice recommendations be reconciled? It seems unlikely that the differences between these recommendations are driven primarily by differences in resource availability or care environments. Rather, they are likely driven by differences in balancing the largely unknown risks and benefits of different approaches. Given that there appears to be some risk of acquiring neonatal infection after birth, it follows that the safest care for the newborn, in terms of minimizing this risk, would be separation from the infected mother. This approach may be particularly justified given the low neonatal infection rates in China, where consensus guidelines recommend mother-newborn separation. Conversely, separation limits opportunities for parent teaching, has known risks of breastfeeding disruption, and may have negative short- and long-term impacts on maternal mental health and mother-newborn bonding. Although separation would theoretically lower infection risk during hospitalization, the impact of separation on infection risk after discharge from the hospital is unknown. Rooming-in during hospitalization, by allowing for the demonstration and teaching of infection prevention practices to the family, might even lower the infection risk when the family is caring for the newborn at home; this may be particularly true for socially vulnerable families without alternatives to high-density living quarters. These uncertainties are reflected in clinical practice; practice surveys of hospitals in Massachusetts have revealed wide variation in protocols, with some centers following AAP guidance and recommending mother-newborn separation and other centers using CDC and WHO guidance to recommend shared decision-making or rooming-in.
In this issue of Pediatrics, Perlman et al17 seek to inform these management questions by starting to address the paucity of data on newborn outcomes in models of care that include rooming-in. The authors share their experience with 31 newborns born to mothers with COVID-19 over a 3-week period at their center in New York City.17 This complements obstetric-focused reports from 2 other New York centers in which brief descriptions of 18 and 29 exposed newborns are included.18,19 Although all 3 series are modest in size, they likely are the largest published series from the United States, which is not surprising given the patterns of COVID-19 in this country.
In the Perlman report, the 31 newborns did well during their birth hospitalization. Twenty-nine were term, roomed-in with mothers, and breastfed depending on maternal choice. All had negative PCR test results for SARS-CoV-2 and were discharged from the hospital with their mothers at 1 to 2 days of life. Two were preterm, required continuous positive airway pressure, and have had uncomplicated courses in the NICU. Both had negative PCR test results at 1, 2, 7, and 14 days of life. The authors suggest their outcomes reflect the importance of several aspects of their care, including surge preparation, adequate personal protective equipment, rapid turnaround of SARS-CoV-2 test results, and their ability to minimize the risk of horizontal viral transmission through careful attention to infection prevention practices. The latter may be the most interesting; to what extent does this report address concerns for infection risk with a rooming-in approach to care?
The answer is likely some, but not much. Knowing that all term infants born to mothers with COVID-19 roomed-in with unremarkable newborn hospitalizations is clearly reassuring. Although the sample size is limited, it matches the largest reported series from China. However, much more needs to be known. What precautions were used to minimize infection risk during the postbirth hospital course? What was the approach to skin-to-skin care and direct mother-newborn contact? Were restrictions placed on family members? Were changes made to routine interventions such as hearing screens or circumcisions? What practices were in place around environmental cleaning? Most important, how did the newborns do after discharge?
This report highlights at least 3 critical and time-sensitive needs for research around neonatal care and outcomes related to COVID-19: (1) much larger sample sizes, reflecting diverse populations that allow for reliable measurement of outcomes; (2) detailed descriptions of care practices, particularly around infection prevention, with ability to assess the comparative effectiveness of different approaches; and (3) follow-up information on maternal and neonatal outcomes after the birth hospitalization. Clearly, single-center reports, even from New York, will not be able to address these needs. Fortunately, multicenter collaborations have already been launched that should. Several of these are summarized in Table 2.
Selected Multicenter and National Collaborations on COVID-19 and Newborns
| Organization . | Registry . | Web Site . |
|---|---|---|
| AAP Section on Neonatal Perinatal Medicine | NPC-19 | https://services.aap.org/en/community/aap-sections/sonpm/ |
| Vermont Oxford Network | COVID-19 Impact Audit | https://public.vtoxford.org/covid-19/ |
| Imperial College of London | PAN-COVID | https://pan-covid.org/ |
| European Society of Pediatric and Neonatal Intensive Care | EPICENTRE | https://espnic-online.org/COVID-19-Outbreak/EPICENTRE |
| Organization . | Registry . | Web Site . |
|---|---|---|
| AAP Section on Neonatal Perinatal Medicine | NPC-19 | https://services.aap.org/en/community/aap-sections/sonpm/ |
| Vermont Oxford Network | COVID-19 Impact Audit | https://public.vtoxford.org/covid-19/ |
| Imperial College of London | PAN-COVID | https://pan-covid.org/ |
| European Society of Pediatric and Neonatal Intensive Care | EPICENTRE | https://espnic-online.org/COVID-19-Outbreak/EPICENTRE |
EPICENTRE, European Society of Pediatric and Neonatal Intensive Care Neonatal COVID Pediatric Neonatal Registry; NPC-19, National Perinatal COVID-19 Registry; PAN-COVID, Pregnancy and Neonatal Outcomes for Women with Coronavirus Disease 2019.
SARS-CoV-2 has infected millions of people worldwide. Nevertheless, fundamental questions remain on how best to care for newborns born to mothers with COVID-19. Perlman et al17 are to be applauded for driving forward this discussion and helping to identify critical questions; it will take all of us working together to answer them.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-1567.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Comments
RE: Response to Comment
We appreciate and agree with the comments by Drs. Sola, Rodriguez, and Golombek. In fact, since the initial publication of the article by Perlman et al 1 and our commentary, much more has been learned about the impact of perinatal COVID-19 by hospitals and regional collaboratives, including the Ibero American Society of Neonatology (SIBEN). New publications of outcomes of SARS-CoV-2 in pregnancy appear almost daily. Among the larger series is a publication from the United Kingdom Obstetric Surveillance System (UKOSS) that describes their experience with over 400 pregnant women with confirmed infection.2 Additionally, the regularly updated dashboard from the American Academy of Pediatrics (AAP) Section on Neonatal Perinatal Medicine (SoNPM) currently reports data on nearly 3000 mother-infant dyads.3 Results from these series have been impressively consistent and similar to those reported by SIBEN, with low rates of neonatal infection and very high rates of reassuring neonatal outcomes. Appropriately, this experience has informed clinical practice. For example, the AAP has revised their initial recommendation relating to separation of the mother and newborn to updated guidance supporting rooming-in and shared decision-making.4
It is encouraging that the international experience to date has supported family-centered approaches to the care of the COVID-19 positive mother and her newborn, including rooming-in and breastfeeding with appropriate infection control practices. As Drs. Sola, Rodriguez, and Golombek remind us, in the setting of uncertainty, we must carefully evaluate risks to mother and newborn while striving to avoid disruption of family-centered care.
Finally, it is important to note that publications to date have largely focused on short-term neonatal outcomes during the birth hospitalization. Information on newborn outcomes after hospital discharge remains sparse. As we continue to respond to the ongoing pandemic, it becomes even more important for the perinatal community to understand the longer term risks and outcomes of COVID-19 in pregnancy, particularly in the context of disparate, possibly socially derived complications such as Multisystem Inflammatory Syndrome in Children (MIS-C) that have become prevalent in some of our communities.5 This now is the challenge for SIBEN, UKOSS, SONPM, and others.
Munish Gupta
John AF Zupancic
DeWayne M Pursley
1. Perlman J, Oxford C, Chang C, Salvatore C, Di Pace J. Delivery Room Preparedness and Early Neonatal Outcomes During COVID-19 Pandemic in New York City. Pediatrics. 2020;146(2):e20201567.
2. Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. Bmj. 2020;369:m2107.
3. American Academy of Pediatrics Section on Neonatal Perinatal Medicine. NPC-19 Registry Update. https://my.visme.co/view/ojq9qq8e-npc-19-registry. Published 2020. Updated 8/29/20. Accessed 9/5/20.
4. American Academy of Pediatrics. FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infect.... Published 2020. Updated July 22, 2020. Accessed 9/5/20.
5. Jiang L, Tang K, Levin M, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. Lancet Infect Dis. 2020.
RE: COMMENT ON Caring for Newborns Born to Mothers With COVID-19: More Questions Than Answers
After reading the detailed review by Gupta et al (1), we submit these comments as recent publications provide additional valuable information to aid in decreasing the extent of uncertainty and gaps in the evidence.
We recently published (2) on 86 mothers Covid-19 PCR positive and their newborns from 11 units of 7 countries in Latin America that report to the network of the Ibero American Society of Neonatology (SIBEN); 68% of the mothers were asymptomatic. Of the 32% symptomatic women, 89% (24) had mild symptoms and 3.5% (3) had severe respiratory symptoms. No mother died. The C-section rate was 38%, and gestational age was <37 weeks in 6% of the cases. RT-PCR was performed on all newborns between 16 and 36 hours of life; in 6 (7%) the swab result was positive. All of them presented mild and transient respiratory distress; none died. The findings also showed significant disparity in care in relation to mother-infant separation and the frequency of breast feeding.
The majority of the cases reported to date have shown that vertical transmission is extremely unlikely. However, one neonate whose mother was infected in the last trimester presented with neurological compromise and had confirmed transplacental transmission of SARS-CoV-2 (3) by maternal viremia, placental infection with very high viral load and neonatal viremia. In another case (4), vertical transmission of the virus was considered possible in a mother with critical illness, finding the virus in amniotic fluid. Two other cases were reported (5) with positive PCR results for SARS-CoV-2 in the mother, neonate, and the placental tissues. Utilizing RNA in situ hybridization assay, the virus was visualized directly by evaluating the presence of the SARS-CoV-2 spike protein mRNA as the molecular target. The presence of SARS-CoV-2 RNA in the syncytiotrophoblasts demonstrates the presence of the virus on the fetal side of the placenta (5).
Human milk is the gold standard for infant feeding and maternal infant bonding. It is a basic human right of all newborns to be with their mother and to be breast fed if the mother so desires and breast milk samples have uniformly been negative (1).
Admittedly, the dearth of high-quality evidence considerably compromises the ability to provide guidance effectively to extremely vulnerable persons, like pregnant and lactating women and infants. New information incorporated into clinical recommendations and guidelines should highlight the uncertainty, clearly define existing gaps in the evidence and, of course, do not increase transmission risks. SIBEN’s guidelines, developed since the end of March, suggest no separation of the mother-infant dyad, and strongly support breast feeding in a shared decision-making process - of course implementing all known and well described measures to prevent viral transmission.
While we wait for further scientific evidence, it is paramount to remind us of the Latin phrase “Primum Non Nocere” (first, do no harm, attributed to Hippocrates), since neonatal medicine without humanism is not really neonatal medicine.
Augusto Sola1 ORCID 0000-0002-7608-3872
Susana Rodríguez1 2 ORCID 0000-0001-6015-6048
Sergio G. Golombek1 3 ORCID 0000-0003-0387-8989
1 Ibero American Society of Neonatology (SIBEN)
2 Hospital Nacional J.P. Garrahan, Buenos Aires, Argentina
3 Hackensack University Medical Center, Hackensack, NJ
References:
1. Gupta M, Zupancic JAF, Pursley DM. Caring for Newborns Born to Mothers With COVID- 19: More Questions Than Answers. Pediatrics. 2020;146(2):e2020001842
2. Sola A, Rodríguez S, Cardetti M, Dávila C. Perinatal COVID-19 in Latin America. Rev Panam Salud Publica. 2020;31;44:e47. doi: 10.26633/RPSP.2020.47. eCollection 2020.
3. Vivanti AJ, Vauloup-Fellous C, Prevot S, Zupan V, Suffee C, Do Cao J, Benachi A, De Luca D. Transplacental transmission of SARS-CoV-2 infection. Nat Commun. 2020;11(1):3572. doi: 10.1038/s41467-020-17436-6
4. Zamaniyan M, Ebadi A, Aghajanpoor S, Rahmani Z, Haghshenas M, Azizi S. Preterm delivery, maternal death, and vertical transmission in a pregnant woman with COVID-19 infection. Prenatal Diagnosis. 2020;1–3. DOI: 10.1002/pd.5713
5. Patanè L, Morotti D, Giunta MR, Sigismondi C, Piccoli MG, Frigerio L, Mangili, G, Arosio M, Cornolti G, Vertical transmission of coronavirus disease 2019: severe acute respiratory syndrome coronavirus 2 RNA on the fetal side of the placenta in pregnancies with coronavirus disease 2019-positive mothers and neonates at birth. American Journal of Obstetrics & Gynecology MFM (2020), doi: https://doi.org/10.1016/j.ajogmf.2020.100145.